Issued by: Centers for Medicare & Medicaid Services (CMS)

Issue Date: April 20, 2016

Program Area: HHS Risk Adjustment Data Validation (HHS-RADV)

Question: Do all issuers of risk adjustment covered plans need to hire an Initial Validation Audit (IVA) entity for purposes of 2015 HHS Risk Adjustment Data Validation (HHS-RADV)?

Answer: Given that 2015 HHS-RADV is a 'pilot year' and audit results will not adjust issuers' payments, CMS will not enforce the 2015 HHS-RADV requirements for: (1) issuers that have no risk adjustment covered plans in the individual and small group markets in the 2016 benefit year; and (2) issuers with 12,000 or fewer billable member months in the individual and small group markets combined statewide as of the April 1, 2016 data submission deadline for 2015 benefit year risk adjustment. CMS has determined that issuers with 12,000 or fewer billable member months have a disproportionately higher administrative burden to participate in the pilot year of HHS-RADV and thus, CMS will not enforce participation for issuers with 12,000 or fewer billable member months in 2015 HHS-RADV. We note that issuers who previously met the criteria as of the February 2, 2016 data submission and received letters from CMS that we would not enforce participation, continue to not be required to participate in 2015 HHS-RADV.

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